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Provider Notice issued 05/24/13
Verbal orders must be signed before the member of the medical staff, the house staff member, or allied health personnel with clinical privileges recommended by the hospital medical staff and granted by the hospital governing board, leaves the area.
Telephone orders may be authenticated by the ordering practitioner or another practitioner who is responsible for the care of the patient and who is authorized to write orders under Illinois law. Telephone orders must be countersigned by the ordering practitioner or another practitioner who is responsible for the care of the patient as soon as practicable pursuant to a hospital policy approved by the medical staff, but no later than 72 hours after the order was given.
Hospital Provider Audits and Requirements for Inpatient Medical Records and Inpatient Admission Orders
| To: | Participating Medical Assistance Program Hospital Providers |
| Date: | May 24, 2013 |
| Re: | Hospital Provider Audits and Requirements for Inpatient Medical Records and Inpatient Admission Orders |
This Notice serves to inform hospital providers about the Department of Healthcare and Family Services (the department) Office of Inspector General's (the OIG): 1) audit standards for services payable by the department's Medical Assistance Program (Medicaid), 2) requirements for the content of inpatient medical records for services payable by Medicaid, and 3) signature requirements for hospital medical records including inpatient admission orders for services payable by Medicaid.
Audit Standards for Hospitals
Medicaid-participating hospitals are required to comply with all applicable federal and state laws and regulations, including, but not limited to, the Illinois Hospital Licensing Act and its implementing regulations. This requirement is set forth in the "Agreement for Participation" executed by the hospital. Failure by a hospital to comply with applicable federal and state law will result in an OIG audit discrepancy finding that is subject to recoupment.
Medicaid-participating hospitals are required to comply with all requirements and standards in the audited provider's hospital policies and procedures. "Hospital policies and procedures" means those policies and procedures that are adopted by the hospital or its medical staff and include, but are not limited to, hospital or medical staff bylaws, policies, procedures, rules, and regulations.
Upon initiation of a hospital audit, the OIG will request that a hospital produce its hospital policies and procedures. The OIG's determination that the hospital failed to comply with the requirements and standards set forth in the hospital policies and procedures, or a hospital's failure to produce its hospital policies and procedures, will result in an OIG audit discrepancy finding that is subject to recoupment.
Inpatient Medical Records and Inpatient Admission Orders
Content
Medicaid-participating hospitals must maintain a medical record with a valid inpatient admission order for each inpatient. The inpatient medical record, together with the admission order, must contain information to justify patient admission and continued hospitalization, support the diagnosis, and describe the patient's progress and response to medications and services.
All inpatient medical record entries and inpatient admission orders must be legible, complete, dated, timed, and authenticated in written or electronic form. Authentication means identification of the author of a medical record entry by that author, and confirmation that the contents are what the author intended.
Written signatures or initials, and electronic signatures or computer-generated signature codes, are acceptable as authentication. Stamped signatures are not acceptable. All authentications must include the initials of the signer's credentials.
Signature Requirements
The department requires hospital medical records and inpatient admission orders to be signed, and for the signature to be legible. An inpatient admission order must be signed by a member of the medical staff with admitting privileges.
If, while conducting an audit, the OIG determines that the signature on a medical record or an admission order is illegible, the OIG will offer the hospital provider an opportunity to timely submit an attestation statement or a signature log for the purpose of authenticating the record. (Signature logs, signature cards, or other unique hospital identifiers are sufficient.)
The guidelines below will govern the OIG in determining whether provider signature requirements are met during the audit process:
| Issue | Column I Signature Requirement Met? | Column IIContact Provider for Follow-Up? |
|---|---|---|
| Legible full signature (handwritten or electronic) | X |
|
| Legible first initial and last name | X |
|
| Illegible signature over a typed/printed name | X |
|
| Illegible signature where letterhead, etc. indicates the identity of the signatory | X |
|
| Illegible signature NOT over a typed/printed name, but accompanied by a signature log or attestation statement | X |
|
| Illegible signature NOT over a typed/printed name, and NOT accompanied by a signature log or attestation statement |
|
X |
| Initials over a typed/printed name | X |
|
| Initials over a typed/printed name, and accompanied by a signature log or attestation statement | X |
|
| Initials NOT over a typed/printed name, and NOT accompanied by a signature log or attestation statement |
|
X |
| Unsigned handwritten note where other entries on the same page in the same handwriting are signed | X |
|
| Signature stamp |
|
X |
| "Signature on file" |
|
X |
| No signature |
|
|
If the guidelines indicate that the hospital provider should be contacted for follow-up (Column II), the OIG will contact the hospital and offer the opportunity to submit an attestation statement (described below) or a signature log within 21 calendar days. The 21 day timeframe begins on the date of the OIG's contact with the provider. If the hospital does not timely authenticate the medical documentation through submission of an attestation statement or a signature log, the OIG will find a discrepancy that is subject to recoupment.
Unsigned medical records and inpatient admission orders are unauthenticated records and the provider will not be given the opportunity to submit supplemental information. In this situation, the OIG will find a discrepancy that is subject to recoupment. In the case of an unauthenticated inpatient admission order, the department will seek to recoup the Medicaid payment for the entire inpatient stay.
Attestation Statement
A valid attestation statement must be signed and dated by the author of the medical record entry or inpatient admission order that is in question, and must contain the name of the Medicaid recipient.
Providers that submit an attestation may use the following statement (though use of this form is not mandatory):
I, [print full name of the provider], hereby attest that the medical record entry/inpatient admission order for [date(s) of service] accurately reflects signatures/notations that I made in my capacity as a/an [insert provider credentials, e.g., M.D.] when I treated/diagnosed [patient name], a Medicaid recipient. I do hereby attest that this information is true, accurate, and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.
The OIG will consider attestation statements for illegibly signed medical records and inpatient admission orders. The OIG will not consider attestation statements where there is no medical record or, in the case of an inpatient admission order, where the order is missing or is not signed.
The OIG will consider attestations that meet the above requirements regardless of the date the attestation was created, except in those cases where department law, regulations, handbooks, or other authority specifically indicates that a signature must be in place prior to a given event or a given date.
Bradley K. Hart
Inspector General